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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800167
Report Date: 01/24/2022
Date Signed: 01/24/2022 02:29:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2020 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200504114244
FACILITY NAME:DULCE VILLA IFACILITY NUMBER:
331800167
ADMINISTRATOR:MODY, NIKULFACILITY TYPE:
740
ADDRESS:66147 S AGUA DULCE DRTELEPHONE:
(760) 251-7842
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY:6CENSUS: 2DATE:
01/24/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Manuel RamasTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Resident sustained stage 3 pressure injury while in care.
Facility did not ensure changes in resident's condition were reported to a physician in a timely manner.
Staff did not assist residents with medications as needed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver findings for the above allegations. LPA Williams identified herself to Caregiver, Manuel Ramas, who was also informed of the purpose of the visit. LPA Williams discussed the findings with the Administrator via telephone. The Department investigation included records review and interviews with staff, residents, and witnesses.

In regards to allegation #1, the Department's investigation revealed that facility staff neglected to assist Resident #1 (R1) in meeting care needs. According to the investigation, in late March 2020, R1 experienced an unwitnessed fall. Following the fall, R1 experienced weakness and needed additional assistance with incontinent care and mobility. Department staff interviewed Staff #1 (S1) who stated that after R1’s fall, R1 preferred to stay mostly in bed. According to additional staff interview, staff observed multiple pressure “ulcers” on both of R1 buttocks. Staff reported that they notified S1 of what was observed approximately three weeks before R1 hospitalization on 4/8/2020. Investigation revealed that despite S1 indicating that R1's
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 18-AS-20200504114244
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DULCE VILLA I
FACILITY NUMBER: 331800167
VISIT DATE: 01/24/2022
NARRATIVE
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Primary Care Physician (PCP) was contacted about the “ulcers,” there is no documentation on file to support that the PCP was notified nor that R1 was receiving any treatment for the “ulcers.” Furthermore, according to PCP interview, no contact was made by S1. In addition, PCP reported that R1 had history of pressure ulcers and needed two-persons to assist in transferring R1 in and out of bed. After the fall in March 2020, R1 needed incontinent care to be provided by staff at night (NOC) shift and needed to be repositioned. However, staff reported that they did not consistently reposition R1 nor change R1 incontinent care product during the NOC shift.

On or around 4/8/2020, the PCP was sent a photo of R1’s ulcers. Following receipt of the photo, PCP requested emergency medical services be sought. On 4/8/2020, 911 Emergency services were called and R1 was sent to the hospital. Medical records revealed that there were four pressure injuries; (1) a 5cm Stage III pressure injuries to R1’s right lower buttock and (2) Stage III pressure injury to upper posterior thigh and (3) 1-2cm Stage II pressure injuries on right buttock and (4) Stage II pressure injuries on left buttock. Based on sufficient evidence to corroborate neglect caused by the facility staff to the resident, the allegation is substantiated. Due to immediate health and safety risk posed to resident in care, an Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that an enhanced civil penalty may be assessed based on Health and Safety Code 1569.49(f).

In regards to allegation #2, Department staff interviewed R1’s primary care physician who stated, “I have never had contact in my life with facility staff.” R1’s primary care physician stated that the office only learned of R1’s pressure ulcer when a photo of the pressure ulcer was sent to the office from R1’s phone. In addition, there was no documentation provided by the facility which indicated that R1's primary care physician was aware of R1's pressure injury. Based on interviews and records review, there was sufficient evidence to corroborate the allegation; therefore, the allegation is substantiated.

In regards to allegation #3, Department staff reviewed residents' Medication Administration Records (MAR) at 0930 hours. During the review, Department staff reported that one resident's MAR was marked as completed in advance by facility staff at 2000 hours. Department staff questioned the Administrator about the discrepancy, to which the Administrator stated that the MAR was marked as completed in advance because they were unaware if they would be present later. Based on the Administrator's statement and review of MAR, there was sufficient evidence to corroborate the allegation; therefore, the allegation is substantiated.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 18-AS-20200504114244
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DULCE VILLA I
FACILITY NUMBER: 331800167
VISIT DATE: 01/24/2022
NARRATIVE
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Based on the evidence gathered during the course of the investigation, the three allegations as stated above are SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where this report (LIC 9099, 9099C, & 9099D) and appeal rights were discussed and a copy was provided to Ramas at the conclusion of the visit.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 18-AS-20200504114244
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DULCE VILLA I
FACILITY NUMBER: 331800167
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/25/2022
Section Cited
CCR
87468.2(a)(8)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ...l care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation.... This requirement was not met as evidenced by:
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An immediate civil penalty for $500 is being assessed for neglect resulting in the injury/illness of resident in care. In addition, the Licensee shall conduct training on the personal rights of all residents for all facility staff and send proof to the Department by POC date of 1/25/2022.
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Based on interviews and records review, the Licensee did not ensure the personal rights of R1 to be free of neglect. The Licensee did not seek medical attention for pressure injury sustained by R1. This posed an immediate health and safety risk to residents in care.
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Request Denied
Type A
01/25/2022
Section Cited
CCR
87466
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87466 Observation of the Resident- The licensee shall ensure that residents are regularly observed for changes in physical... the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician.. This requirement was not met evidenced by:
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The Licensee shall conduct training on regulation 87466- Observation of the Resident for all facility staff and send proof to the Department by POC date of 1/25/2022.
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Based on interviews and records review, the Licensee did not ensure changes in resident's condition were documented and reported to R1’s physician in a timely manner. This posed an immediate Health and Safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 18-AS-20200504114244
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DULCE VILLA I
FACILITY NUMBER: 331800167
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
01/31/2022
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed.. The plan shall encourage routine medical care.. provide for assistance in obtaining such care, ... (5) The licensee shall assist residents with self administered medications as needed. This requirement was not evidenced by:
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The Licensee shall conduct medication training and documentation for all staff in accordance with regulation 87465. Proof of the training shall be sent to the Department no later than POC date of 1/31/2022.
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Based on interviews and records review, the Licensee did not ensure that resident medications were dispensed appropriately and as prescribed. This posed a potential Health and Safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2020 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200504114244

FACILITY NAME:DULCE VILLA IFACILITY NUMBER:
331800167
ADMINISTRATOR:MODY, NIKULFACILITY TYPE:
740
ADDRESS:66147 S AGUA DULCE DRTELEPHONE:
(760) 251-7842
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY:6CENSUS: 2DATE:
01/24/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Manuel RamasTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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2
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Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver findings for the above allegations. LPA Williams identified herself to Caregiver, Manuel Ramas, who was also informed of the purpose of the visit. LPA Williams discussed the findings with the Administrator via telephone. The Department investigation included records review and interviews with staff, residents, and witnesses.

At the time of visit, LPA Williams observed that the kitchen sink was functioning properly. LPA interviewed the Administrator who stated that they have issues with the sink; however, they have called the plumber to address the issue many times. LPA collected receipts which appeared to show services provided for the kitchen sink. LPA Williams observed no other appliances in disrepair at the time of visit.

Based on evidence obtained during the investigation, this agency has determined that the above allegation is UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 18-AS-20200504114244
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DULCE VILLA I
FACILITY NUMBER: 331800167
VISIT DATE: 01/24/2022
NARRATIVE
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An exit interview was conducted where this report(LIC 9099 & 9099C) were discussed and a copy was provided to Ramas at the conclusion of the visit.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7